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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Retained Placenta Management (552)

Objectives

The aim of this guideline is to standardise management of retained placenta in order to minimise harm to the patient and reduce the risk of associated PPH.  

Please report any inaccuracies or issues with this guideline using our online form

Retained placenta is defined as a placenta that remains in the uterus 30 minutes after active management of the third stage or 60 mins if management of the third stage is conservative .This occurs in 2-3% of all deliveries and is a risk factor for post partum haemorrhage (PPH). Haemorrhage, infection and genital tract trauma are recognised complications of the management of retained placenta. 

Associated GGC policies:

Risk factors for retained placenta

  • Previously retained placenta
  • Multiparity
  • Maternal age > 35 years
  • Induction of labour
  • Preterm labour
  • Placenta Previa / abnormally invasive placenta
  • Uterine anomalies eg. Bicornuate uterus, fibroids
  • Previous uterine surgery or instrumentation

Causes

  • Full Bladder
  • Constriction ring
  • Morbidly adherent placenta
  • Detached cord
  • Uterine anomaly

Management of 3rd Stage

If the placenta is undelivered after 30 minutes of active management / 60 minutes ofconservative management and patient stable with no significant bleeding

  • Do not leave woman unattended
  • Regular maternal observations : pulse, blood pressure, respiratory rate every 15minutes
  • Position change to upright
  • Empty the bladder. If cannot pass urine then catheterisation should be carried out
  • Encourage breastfeeding or nipple stimulation
  • Call Obstetric specialty trainee earlier if concerns regarding bleeding or becomes haemodynamically unstable

Conservative management only : at 60minutes if placenta not delivered  give 10iu IM syntocinon and wait a further 30 minutes if no active bleeding.

If undelivered by 45 minutes active /  90 minutes conservative

  • Call Obstetrics Specialty Trainee to review and inform labour ward co-ordinator
  • Regular maternal observations : pulse, blood pressure, respiratory rate every 15minutes
  • Site IV access - large bore 16G grey cannula, and obtain FBC/ G+R
  • Commence IV fluids - 1000ml crystalloid ( Compound sodium lactate (Hartmanns) solution or Sodium Chloride 0.9%)
  • If bleeding consider syntocinon infusion (40iu syntocinon in 500ml sodium chloride 0.9% or compound sodium lactate at 125ml/hr). Do not start routinely as may make MROP more difficult.
  • Accurate weighed estimated blood loss should be documented as a running total.

Obstetric Specialty Trainee:

  • Offer vaginal examination
  • Examination in the room is appropriate with verbal consent and if signs of separation have occurred, providing analgesia is adequate. Be prepared to abandon attempts and move patient to theatre if there is active bleeding or patient discomfort.
  • Use of umbilical vein uterotonic drugs is no longer recommended
  • Obtain informed consent for theatre
  • Inform anaesthetist and theatre staff
  • If there is significant delay in transfer to theatre consider indwelling catheter and cross match

Consent should include:

Risks of bleeding, infection, trauma to uterus or cervix, failure to remove all tissue, blood transfusion, repeat procedure, balloon insertion, laparotomy  and hysterectomy.

Theatre procedures

  • Surgical pause and review of consent
  • Ensure analgesia is functional
  • Aseptic technique - clean and drape
  • IV Antibiotic cover - 1.2g of co-amoxiclav OR clindamycin 600mg IV + gentamicin
  • Empty bladder
  • Stabilise fundus with non dominant hand
  • Gently insert hand through cervix and identify the placental plane
  • If plane between placenta and uterus not easily defined consider placenta accreta and inform on call consultant. Do not pull on cord or placenta.
  • Using the side of your hand and a sweeping motion sweep the placenta from the uterine wall
  • Guard the fundus to avoid uterine inversion
  • Grasp the uppermost portion of the placenta and aim to remove the whole placenta in one piece
  • Check the cavity is empty - if in doubt call obstetric consultant on call
  • Massage fundus
  • Inspect for tears and repair as required
  • IV syntocinon infusion should commence ( 40iu of syntocinon – 500ml of Compound sodium lactate over 4hours if active bleeding has occurred)
  • Document in notes and debrief patient when appropriate
  • DATIX to be completed if PPH or other complications
  • Use of PPH section in notes to be completed where appropriate.

Post-op debrief

Patients who have had a retained placenta should be advised that all future deliveries should occur in an obstetric led unit as they have a higher risk of post-partum haemorrhage.

Second trimester loss: retained placenta

Conservative management may be considered for up to 180minutes in the absence of bleeding or shock. However if no signs of separation have occurred within 60minutes then manual removal may be appropriate. 

Editorial Information

Last reviewed: 01/08/2022

Next review date: 31/08/2027

Author(s): Judith Roberts.

Version: 2

Approved By: Obstetric Clinical Governance Group

Document Id: 552

References

National Institute for Clinical Excellence (2014) Care of healthy women and their babies during childbirth. CG190: NICE.